We see, read, and hear so much about horizontal violence and nurses not being supportive of each other, and also about other healthcare professionals being unsupportive of nurses. Another such case is occurring, but what is striking to me, is that while this one nurse is going through this tough time, nurses on the web are rallying together to support her and encouraging others to do the same.

The case is of Amanda Trujillo, a registered nurse in Arizona. According to a letter she wrote and the posts of many nurse bloggers, Amanda has been fired from her job, her nursing license is in question, and she is undergoing psychiatric evaluation after educating a patient about his illness and options. The patient decided to forgo surgical intervention and explore hospice care. The details of her case can be read on a number of nursing blogs, including vdutton’s posterous (with the transcript of details recorded by her attorney), Those Emergency Blues, and Emergiblog. The Nerdy Nurse also has several posts and an extensive list of resources about the case and ways to show support.

I can think of several instances where patients I’ve cared for had questions that either were not answered by the healthcare team or were answered, but the patient did not fully understand his condition or options. On many  occasions in my nursing career, I provided patient education that helped a family make an  informed decision. I’ve called together family meetings with the healthcare team and requested ethics committee consultations. Advocating and educating patients, within the scope of nursing practice and institution policies, of course, is our responsibility. 

I will be following the case to see what evolves and the response of nursing organizations. Thank you to the nurses who have been sharing Amanda’s story.

When I started to think about a special post to write for Thanksgiving, I tried to remember a time when I really grew as a nurse. There was no question in my mind about a certain patient that was instrumental in that growth. The crazy thing was I never even knew her.

It started out like any other shift – I was assigned two patients (we were fully staffed), a wonderful leader and my former preceptor was our charge nurse for the evening, and a team of interns and residents who had been in our Medical Intensive Care Unit for a few weeks were working. All the beds were full and none of our patients were up for transfer out of the unit, so it seemed like we were in for a calm shift.

Linda was a young woman who had a uterine rupture during childbirth and had lost a lot of blood. She subsequently developed acute respiratory distress syndrome (ARDS) and had come to our unit about 2 weeks prior to this particular evening for intubation and management of her ARDS. She had no significant past medical history, no known allergies, and had an uncomplicated pregnancy with regular prenatal care.

During change-of-shift report, I learned from the day shift nurse that the MICU team had met with Linda’s family that day after a neurological exam and testing had revealed that Linda was brain dead. The family had decided to gather together this evening and we’d remove Linda from the ventilator. They had also requested to donate her organs.

A representative from Gift of Life arrived shortly after the start of my shift and the family started to drift in as well. Never had I been part of such an emotional patient experience. The strength and courage of the family of this young woman – this new mother – was incredible. While their grief was palpable in the room, so was their faith. They verbalized gratitude at being fortunate enough to be able to donate several of Linda’s organs and saw this as a way to continue her life.

So, this special thank you goes out to Linda and her family…

Thank you for allowing me to be part of that night.

Thank you for sharing your faith with me.

Thank you for sharing your stories with me.

Thank you for teaching me that death, even a tragic one, can give us strength that we might not even know is within us.  

Thank you for thinking of others and giving life. 

Living wills. Life support. Do-Not-Resuscitate. These are all phrases that I used frequently working in an adult medical intensive care unit. I rarely had trouble using the words death, dying, hospice, or end-of-life with patients and families.

However, outside of the hospital, these words have been a lot harder for me. My parents do have living wills and have expressed their wishes to me, but not because I initiated any discussion with them. In fact, I’ve actually avoided those conversations despite knowing how important they are. 

There is not really a good time to have end-of-life discussions, so people tend to wait for the "right time" which often turns into the "wrong time" or "too late." The conversation might end up taking place in the hallway of the emergency department or in a critical care waiting room. Sometimes, information is conveyed and decisions are even made over the phone.

I am fortunate that my own family members have insisted on preparing for the end of their lives and sharing their plans and wishes with me. As a daughter, I really don’t like to hear about it. As a nurse, I know that this is a very good thing.

Saturday, April 16th is National Healthcare Decisions Day. Make this day the "right time" to talk with your loved ones and encourage the patients you care for to do the same.

Providing end-of-life care can be one of the most challenging responsibilities as a nurse, yet can also be one of the most fulfilling. When a patient’s wishes are respected and dying with dignity is a priority, death can be a peaceful and positive experience for the patient, his family, and the staff caring for him.

Oftentimes, our focus during end-of-life care is primarily on pain management and relieving or preventing labored breathing. Research published last month in the Archives of Internal Medicine calls attention to other factors that need to be addressed to improve care at the end of life. These include communication deficits, the importance of dyspnea assessments, implantable cardioverter/defibrillator deactivation, and bowel regimens.

In my opinion, the importance of communication at the end of life cannot be stressed enough. This includes communication among staff, among the patient and his family members, and between staff and the patient and his family. How many times have you encountered family members who didn’t agree with the wishes of a loved one as stated in his living will or who didn’t understand that an illness was terminal? How about physicians, nurses, and other professionals who were reluctant to address end-of-life issues?

It is important for all decision-makers and caregivers to understand and agree on a plan in order to ensure a positive experience at the end of life. For this to happen, communication is key. Take some time to read the following articles. You’ll find some great information to help educate patients, families, yourself, and your colleagues about end-of-life issues and care.

• Life-Support Interventions at the End of Life: Unintended Consequences
• Beyond Bad News: Communication Skills of Nurses in Palliative Care
• LEADERSHIP DIMENSION: Empowering Family Members in End-of-Life Care Decision Making in the Intensive Care Unit
• Partnering with Palliative Care 

An article about end-of-life care received front page billing in The Philadelphia Inquirer this past Sunday. The article A look at the new field of palliative care describes the case of a previously active 74-year old woman who became seriously ill. When a meeting was set up with the palliative care team, family members expressed concerns about “death panels” and “pulling the plug.” They did not anticipate that the goals of this first family meeting were to talk about managing their loved one’s pain, answer questions, and provide information to help them make decisions about her care.

The article goes on to describe the role and goals of a palliative care team. With quotes from both the team members and the patient’s family members, this well-written article really serves to educate the public about making end-of-life decisions. It shows us that making decisions about care are not always a matter of live or die, but more an ongoing process about providing appropriate care.  The article also discusses the importance of living wills and having discussions with one’s family before critical illness occurs. 

As a former critical care nurse, I know how satisfying it was when we had what we called a “save” – when a patient near-death turned the corner and got better. I also know how satisfying it was for a patient to have a “good death.” At that time we didn’t have a palliative care team, but we did have plenty of family meetings.  Helping a patient and family have a positive experience and make the right decisions for their family member was an important part of my job. Is there a palliative care team where you work? How are you involved in discussions about end-of-life care?

I read with interest the article in the January issue of AJN, "Life Support Interventions at the End of Life: Unintended Consequences" by Shirley A. Scott.  I recently cared for 2 terminally ill patients who were receiving life support interventions.

The first patient had laryngeal cancer with metastisis requiring intubation and mechanical ventilation. She initially hoped for a cure and underwent several rounds of treatment.  When it became evident that she was not going to improve, she had a conversation with her physician, nurses, and family and told them she had had enough and was ready to die.  Her "hope" was for a pain free, gentle death and that is exactly what she got.

My second patient had end stage liver disease and esophageal varices and wasn't a candidate for further interventions. Even after massive blood product transfusions and experiencing cardiac arrest several times, he "hoped" for a miracle that wasn't coming.  After lengthy discussions with the physician, nurses, and his family, he finally agreed that these "life support interventions" were not bringing life, but were prolonging an inevitable death. 

As nurses we are in a unique position to discuss end of life options with patients and their families that bring them hope for a kinder, gentler passing.  In both of these cases, the end of life conversations involved physicians, nurses, the patients, and their families.  How does your institution handle end of life discussions?